Who may perform the HPI

[sdelth4284]

Who is allowed to perform the HPI?

allowed- Physician, PA, CNP

not allowed- MA?

I've been searching cms.gov but have been unable to find a document that states MAs are not allowed to perform the HPI.

 

[smonahan]

The review of systems and past medical, social, family history may be recorded by nurse or other provider...as long as the signing physician reviews and signs off on the documentation. The chief complaint, history of present illness, exam, and MDM must all the responsibility of the signing provider (MD, DO, APRN, NP, etc.)

 

[Pam Warren]

CMS hasn't exactly come out with clear guidance, but most of the MACs have.

From NGS:

There are two elements of history that can be elicited and documented by someone other than the provider: the Review of Systems (ROS) and the Past, Family and Social History (PFSH). A staff member or medical student may elicit this information from the patient, but the provider is obliged to review it, amend it if necessary, and indicate in writing that he/she has done so. The provider is responsible for eliciting and documenting the History of the Present Illness (HPI), since this requires defined clinical skill. That said, the provider may utilize the services of a Scribe in documenting the HPI, as with any other element of an E&M service.


There are specific rules about using a scribe:

• Does not act independently or function as a physician
• Takes place as provider dictates data into EHR for history/exam/plan of care
• Can also perform medical assistant role
• Enters information on providers? behalf
• Provider can edit EHR note prior to sign off. After that, an addendum must be created.
• Physician cosigns note
• Entry notes indicate name and title of scribe ?acting as a scribe for Dr. ___

__?

 

[sdelth4284]

Thank you, that matches what I've found.